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Evidence Project Research Paper

By: Amy Proietti-Fox, Katelyn Bryce, Megan Stolte, Sophia Wu, and Emily Mills

I.

Introduction
Nurses tend to be burned out when working due to the workload and the amount of hours that they work

per week. This can cause patient outcomes and quality of care to worsen and readmission to increase. This topic
is relevant in the nursing profession because it can have an impact on decreasing readmission rates, healthcare
costs and patient recovery. Therefore, we need to figure out what can we do to try to reduce the readmission
rates and improve the quality of care the patient receives, which would also improve their outcomes.
Our PICO stated, Does working 48 hours or more a week have a direct correlation with patient
readmission rates as compared to those nurses working 36 hours per week? We constructed this question
because of its relevance to the nursing profession.
II.

Comparison of Articles
Upon reviewing our articles, we discovered various similarities between each of them. In all ten articles

that were researched most of the samples being studied were registered nurses currently working in a hospital
that were working more than full time. For all of our articles the study purpose focused on the relationship
between the hours worked and patient outcomes or nurse performance and satisfaction. Another commonality
for our articles was the lack of variables. There were no interventions reported for most of our articles. Four out
of ten of our articles used a questionnaire that nurses evaluated as an instrument to obtain data. For all of our
articles the conclusion resulted in the greater the amount of hours registered nurses worked directly correlates to
negative patient outcomes and greater risk for readmission.
III.

Contrasting Articles
Our articles differed in various aspects related to their sample sizes, locations, and the methods they

used to carry out the research. For all the articles the Sample sizes ranged from 1 to 22,275 registered nurses;
two of the articles did not have a sample size due to its study on previously published articles. One of the

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articles used a simulator as an instrument to measure data; they tested registered nurses during three separate
occasions on assessment and performance. Another article used the Maslach Burnout Inventory which assessed
burnout related to the length of shift. One article used the quality assessment and validity tool for correlation
studies, it had 14 questions that assessed the quality of the research articles used in the study. Similarly, an
article used the logistic regression model and it reviewed the articles to look at the quality of data that was used
in the research. One article checked data before and after adding an extra registered nurse to the floor to take
over shifts, this gave them results based on how the shift length correlated with patient outcome.
Lastly, an article used an evaluative tool for nurses to report their length of shift and how they felt
patient outcome resulted as well as satisfaction of patient care. Only one article had an intervention; the hospital
assigned one extra registered nurse to the unit in order to see the difference in patient outcomes. The locations
where the research was done differed between several articles. Multiple articles were in the United States;
however, there were several that were elsewhere, such as Korea, Ontario, Thailand, the Netherlands and 12
European countries.
IV.

Limitations
Despite our articles being publishable, there were some limitations involved in the studies. The article

that was tested over 12 European countries did not test for interaction effects between country and shift work;
we can only estimate the average effect across all countries and cannot explore differences between countries
related to (for example) cultural differences. (Griffiths, 2014)
In the article that examined the relationship between the time spent on current shift and efficient,
accurate completion of nursing tasks in PICUs. The sample size was small when compared with the initial
power calculation. There wasn't a substantial amount of baseline data available to relate to the standard
deviation of task completion and error rates. Therefore, there may have been an overestimation of the sample
size standard deviation. Additionally, the stimulated environment inhibits blinding participants to timing and
conditions.
The article that determined whether 12 hour shifts in nursing are more beneficial or more negative
toward employees and patient had a limitation that an 8 hour group had a low response rate and the researchers

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did not investigate the reasons that they havent responded. Overall though, the 8-hour group reported the same
data regarding levels of fatigue as the national sample of health workers working 8- hour shifts. Therefore, the
group was still representative of all 8- hour nurses.
In the article that studied the relationship between nurse overtime and adverse patient events in North
Carolina and West Virginia, respondents may have been those who were more concerned with working overtime
when addressing nurse overtime issues or those who had more time to complete the survey. In that case, the
study findings would be biased. Also the sample collected from North Carolina and West Virginia may have
different experiences than nurses from other states. Therefore, this study finding cannot be generalized to apply
to the implementation of mandatory overtime regulations in other states. (Bae, 2013)
The study that provided research from many already published articles had many limitations. One
included not being able to conduct meta-analysis procedures and limited the consolidation of findings because a
variety of nurse and patient outcome measures, heterogeneity of the samples, settings, and analysis precluded
some of the findings (Bae, 2014). Another major limitation was that published research articles tend to only
report their positive giving a high possibility of reporting bias in this review.
The article that studied the extended hours of nurses and its relationship to patient, nurse, and
organizational outcomes had a limitation of its own. The patient outcomes were measured by respondents selfreports (Kunaviktiku, 2015). This leads to the risk of bias results as well.
The article that researched multiple studies had some limitations, such as there were some bias that
remained even though the researchers tried to avoid it. Also, the methods were not perfect because they did not
include the need that the patients have for being in the hospital (Murphy, et al., 2011). Furthermore, the
researchers used cross-sectional data instead of longitudinal data, which would have better suited their purpose
of the study.
The article that assigned one extra registered nurse to their nursing stuff for six months had a few
limitations in their study. One limitation was that only one unit of the hospital was being researched and that
there was only a few participant follow-ups (Yu & Kim, 2015). Also, other nursing-sensitive outcomes were
researched, but they significantly changed within a month after the extra nurse was assigned; therefore, they
were not included in the study due to the short duration of time.

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Limitations for both studies about nurses shift lengths related to negative patient outcomes in
California, New Jersey, Philadelphia, and Florida, were that the samples were not national so it could change
the validity of the results. The study with a sample of 22,275 was a cross-sectional study which was done over a
short period of time so it could possibly affect the results. Another limitation of this study was that the survey
the participants completed was voluntary. Therefore, it would cause a significant change in the results
considering the large sample involved in this study.
V. Implications for Nursing
As mentioned above, nurses tend to burn out more quickly due to the increased workload which directly
impacts patient outcomes and quality of care. After reviewing our articles, the findings included increased
amount of hours worked decreased quality of care. From these findings, we can implement some
recommendations such as hiring 1-5 extra registered nurses to cover the extra hours per unit. This solution can
possibly keep nurses longer because they wont get burned out as fast. Another recommendation is requiring
hospitals to implement a policy that makes the institution meet nursing quota every quarter or they will be fined.
This quota would state that there would a regulated amount of hours that each nurse could work per week. Last
but not least, each nurse should have a required hour long lunch. Nurses are supposed to be advocating for a
healthy lifestyle, but we dont have the time to eat or rest properly which could have an impact on the quality of
nursing practice.

V.

Conclusion
There is overwhelming evidence that suggest that nurses who have longer work shifts experience greater

fatigue that results in poorer quality of care, patient outcomes, and increased readmission rates. There are
several comparisons and differences between our articles; however, both led us to the same conclusion that the
article findings directly correlate the hours worked by nurses and patient outcomes. Although there were

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limitations, none of them were of great significance. From the results of these articles, there were some
recommendations that can be implemented to reduce the potential of negative outcomes. This is important for
the nursing practice and can benefit the health care system and the nursing profession as a whole to identify
these issues.

VI.

References

Calhoun, A. W., Boone, M. C., Dauer, A. K., Campbell, D. R., & Montgomery, V. L. (2014). Using simulation
to investigate the impact of hours worked on task performance in an intensive care unit. American
Journal of Critical Care, 23(5), 387-395 9p. doi:10.4037/ajcc2014756
Bae, S., (2013). Presence of nurse mandatory overtime regulations and nurse and patient outcomes. Journal of
Nursing Economics, 31(2), 59-68.
Bae, S., Fabry, D., (2014), Assessing the relationships between nurse work hours/overtime and nurse and patient
outcomes: Systematic literature review. Nursing Outlook, 62 (2), 138-156.
doi:10.1016/j.outlook.2013.10.009
Griffiths, P., DallOra, C., Simon, M., Ball, J., Rickard, L., Rafferty, A., Aiken, L. (2014). Nurses shift
length and overtime working in 12 european countries. Journal of Med Care, 52(11), 975-981. doi:
10.1097/MLR.0000000000000233
Josten, E., Ng-A-Tham, J., & Thierry, H. (2003). The effects of extended workdays on fatigue, health,
performance and satisfaction in nursing. Journal of Advanced Nursing, 44(6), 643-652 10p.
doi:10.1046/j.0309-2402.2003.02854.x
Kunaviktikul, W., et al., (2015), Nurses extended work hours: Patient, nurse and organizational outcomes.
International Nursing Review, 62: 386-393. doi:10.1111/inr.12195

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Murphy, G., Birch, S., OBrien-Pallas, L., Kephart, G, & MacKenzie, A. (2011). Nursing inputs and outcomes
of hospital care: An empirical analysis of Ontarios acute-care hospitals. Canadian Journal of Nursing
Research, 43(1), 126-146.
Stimpfel, A., Sloane, D., & Aiken, L. (2012). The longer the shifts for hospital nurses, the higher the levels of
burnout and patient dissatisfaction. Health Affairs, 31 (11), 2501-2509. DOI: 10.1377/hlthaff.2011.1377
Stimpfel, A., Lake, E., Barton, S., Gorman, K., & Aiken, L. (2013). How different shift lengths relate to quality
outcome in pediatrics: data bits: does shift length affect patient outcomes and nurse satisfaction. The
Journal of Nursing Administration, 43, 95-100. doi: 10.1097/NNA.0b013e31827f2244
Yu, S. & Kim, T. (2015). Evaluation of nurse staffing levels and outcomes under the government-recommended
staffing levels in Korea. Journal of Nursing Management, 23, 479-486. doi: 10.1111/jonm.12155.

VII.

Draft Table

Summary of Studies Evidence Table

PICO: Does working 48 hours or more a week have a direct correlation with patient readmission rates as
compared to those nurses working 36 hours per week?
Group #5
Group Names: Amy Proietti-Fox, Katelyn Bryce, Megan Stolte, Sophia Wu, Emily Mills
Author/Year
LOE

Sample

Stimpfel et al.,
(2013)

N=3710
registered
nurses

LOE 6

Study
Purpose
To study how
nurses shift
length affects
patient
outcomes and
nurse
satisfaction

Variables
Time and
patient
outcomes

Instruments with
Validity and
Reliability
Nurses were group
into 3 shift categories
which include 8, 12,
and more than 13
hours. It measured job
satisfaction, burnout,

Results/Statisti
cal Evidence

Summary/Conclusion

Negative
outcomes were
common. Poor
outcomes
occurred twice
as much among

The great amount of hours

a nurse works affect
patient outcomes
negatively.

Stimpfel et al.,
(2012)
LOE 6

N=22,275
registered
nurses

To study the
relationship
between longer
nurse shifts, the
levels of
burnout and
patient
dissatisfaction
and how it
negatively
impacts patient
outcomes

Time,
patient
outcomes
and
satisfaction,
and
burnout
rates

quality of nursing care

and safety among the
nurses participating.
They were also asked
to report numbers of
central line associated
bloodstream
infections, UTIs, and
complaints from
patients and their
family members

the participants
who work a 13
hour shift.

Nurses were grouped

by shift lengths: 8-9
hours, 10-11 hours,
12-13 hours, and more
than 13 hours.
Instruments used were
the 4-point Likert
scale-type question
and the Maslach
Burnout Inventory.
There were controlled
variables used to
account for nurse
characteristics,
organizational
features, and hospital
structural
characteristics
because theyre all
related to patient
outcomes. Analysis
included descriptive
statistics to study the
patient outcomes
related to shift length
and a survey to study
the relationship
between numbers of
nurses working per
shift also relating to
patient outcome. This
analysis was done by
the statiscal analysis
software.

Negative patient
outcomes and
patient
satisfaction were
associated with
burnout and job
dissatisfaction in
those that
worked longer
shifts. This was
2 times higher
than the nurses
who only work
8-9 hours.

Nurses who had longer

shifts had higher burnout
and job dissatisfaction
rates associated with
negative patient outcomes
than the nurses who
worked less hours per
shift.

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Griffiths, et al,
(2014)
LOE 5

N= nurses
in 488
Medical
surgical
units

Relationship
between shift
length and
nursing care.

No
interventio
ns were
reported.

Nursesreportedthe
numberofhoursworked,
andevaluatedqualityof
nursingcare.

Bae, S., (2013)

LOE 5

N= 500
RNs

Relationship
between nurse
overtime and
adverse patient
events.

No
interventio
ns were
reported.

Aquestionnairewas
giventonursestoself
reportanypatient
adverseandtheamount
ofhourstheyworked.

Calhoun, et al.,
(2014)

N=28
CCC
nurses

Examine
relationship
between time
spent on current
shift and
efficient,
accurate
completion of
nursing tasks in
PICUs

Time and
accurate
completion
of tasks

N=1791
RN

To study
Thailand
nurses
working over
40 hours per
week and its
relationship to
patient, nurse,
and
organizational
outcomes.

24
esearch
articles
written in
English
and
published
from
January
2000
until
March
2013

To evaluate
the effect of
nurse
overtime and
long work
hours on
nurse and
patient
outcomes.

LOE 5

Kunaviktikul,
et al.,
(2015)
LOE 2

Bae, et al.,
(2014)
LOE 1

Nursesworking
overtimewere
morelikelyto
reportpoor/fair
qualityofnursing
care,poor/failing
patientsafety,and
higherratesof
careleftundone.
Workingmore
than40hoursper
weekwas
positivelyrelated
tothelikelihood
ofreporting
medicationerrors.

Nurses reported working

>12 hours on a shift are
more likely to describe
care as poor.

None were used in this

study

PICU nurses
exhibit
improvement in
task completion
rate with no
degradation of
accuracy during a
12-hour shift.

The rate of task

completion
improved significantly
whereas the accuracy of
task
completion did not
deteriorate during the
standard
12-hour shift worked by
PICU nurses at this
hospital.

Time and
reported
outcomes
of patients
and nurses

Questionnaires: The
Demographic Form;
The Nurses Extended
Work Hour Form; The
Patient, Nurse, and
Organizational
Outcomes Form; The
Organizational
Productivity
Questionnaire; and
The Maslach Burnout
Inventory.

These extended
hours worked
had negative
patient
outcomes. The
extended hours
also had a
correlation with
nurses
outcomes of
emotional
exhaustion and
depersonalizatio
n

Working two shifts (16h)

more than the regular
work hours lead to
negative outcomes for
patients, nurses and the
organization.

Nurse
and/or
patient
outcomes
and nurse
work hours

Researchers started
with using keywords to
find articles and began
an elimination process
to get rid of the ones
that did not have what
they were researching.

Evidence
between long
hours worked by
nurses and the
negative nursing
outcomes are
strong however,
the relationship
between nursing
being
overworked and
adverse patient
outcomes needs
more evidence
and research

There are negative

outcomes from nurses
working too many long
hour shifts and too
many hours per week.
There is not enough
information and
evidence to connect
those long hours
worked with negative
patient outcomes.

Although there were

significant relationships
between the regulation
and adverse patient
events, the regulations did
not have an impact on
patient outcomes.

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Josten et al.,
(2003)
LOE 1

Murphy, et al.,
2011
LOE: 6

Yu, S. & Kim,

T., 2015
LOE: 3

N=134
nurses

Wasnt a
selected
sample
due to just
contributin
g to
evidence
that was
already
published
Collected
by a
hospital in
a surgical
unit where
one extra
RN was
assigned
for 6
months

To determine
whether 12 hour
shifts in nursing
are more
beneficial or
more negative
toward
employees and
patient care.

8,9,and12
hourshifts
satisfaction
andpatient
care
compared.

Thedatawascollected
byaquestionnairesent
byinternalorexternal
mailtoallnurseswho
worked8or9hour
shifts.Thequestionnaire
wasdevelopedbythe
firstauthor,using
existing,reliableitem
scaleswhenpossible.

Thenursesthat
workedthe9hour
shiftsweremore
tiredhadmore
healthcomplaints,
andwereless
satisfiedthan
thosewhoworked
8hourshifts.
Additionally,their
performancewas
slightlypoorer
thanthe8hour
shift.

In conclusion, the 9 hour

shift was not a good
compromise between the
8-hour and 12-hour shifts.
Additionally the 12 hour
shifts were
disadvantageous
regarding fatigue, health,
and performance.

It investigates
relationships
b/w patient
length of stay,
exposure to
nursing care,
readmission
rates, patient
satisfaction
levels, and
patient health
status
Study was
aimed to
evaluate RN
staffing and
outcomes

Nurses and
readmissio
n rates

Used conceptual
framework and logistic
regression models

Hospitals with
more nurses have
a shorter length of
stay and fewer
readmission rates

If there were more nurses,

the readmission rates
would not be as high.

Checked length of stay,

overtime hours, incidents
of death, and nursing job
performance prior and
after adding one extra
RN

When theres an
extra RN, the
length of stay,
patient outcomes,
and overtime
hours were
reduced and
nursing job
performance was
improved

Having an extra RN helps

reduce patient care and
outcomes and also
received better care.

One
additional
nurse and
patient
outcomes